COGNITIVEBEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN NARROWING THE
COGNITIVE-BEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN: NARROWING THE DIVIDE BETWEEN I DEOLOGY AND EVIDENCE Introduction o Integration of nondirective and directive play therapy approaches for child trauma treatment o What is the role of play therapy? • Play therapy as “vehicle to teach CBT skills” (p. 107). • Play as mechanism of change o Play makes treatments developmentally more sensitive o Common ground exists between child-led play therapy and CBT Three possible treatments o Treatment option 1: CBT
COGNITIVE-BEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN: NARROWING THE DIVIDE BETWEEN IDEOLOGY AND EVIDENCE Three possible treatments o Treatment option 1: CBT • Common features of child trauma CBTs • • Thorough assessment and diagnostic formulation Development or enhancement of adaptive coping strategies Psychoeducation Hierarchical exposure to excessively or inappropriately feared stimuli Alteration of thoughts, behaviors, and feelings to alter anxiety level Cognitive restructuring regarding misattributions or excessive guilt Caregiver involvement in treatment to promote caregiver understanding, skill-building, and reinforcement of therapy techniques used with the child • Session 1: assessment • Session 2: psychoeducation • Session 3: identification of different emotions • Response plan to trauma triggers in adaptive ways • Specific coping strategies to use • Parent assists child in recognizing when to use them
COGNITIVE-BEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN: NARROWING THE DIVIDE BETWEEN IDEOLOGY AND EVIDENCE Three possible treatments (cont. ) o Treatment option 1: CBT (cont. ) • Session 4: identification of unhelpful cognitions • Session 5: relaxation techniques taught • Deep breathing • Positive guided imagery • Session 6: Role-play scary thought and application of coping strategy • Session 7: coping skills enhanced for parent • Sessions 8 -11: trauma narrative worked on • Session 12: trauma narrative told to parent • Sessions 13 -16: in vivo exposure tasks • Session 17: termination
COGNITIVE-BEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN: NARROWING THE DIVIDE BETWEEN IDEOLOGY AND EVIDENCE Three possible treatments (cont. ) o Treatment option 1: CBT (cont. ) • Disadvantages of CBT • Difficulty understanding material presented • Cognitive triangle • Metacognition • Boring activities • Cognitive triad worksheet • Verbal didactic method of instruction • Focus on future events and future coping behaviors taxing o Treatment option 2: Child-led play therapy • Basic tenets • • • Emotionally significant experiences best processed through play Enhancement of positive self-concept Enhancement of sense of control and mastery Enhancement of capacity for interpersonal trust Increased self-reliance
COGNITIVE-BEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN: NARROWING THE DIVIDE BETWEEN I DEOLOGY AND EVIDENCE Three possible treatments (cont. ) o Treatment option 2: Child-led play therapy (cont. ) • 41 -session treatment practicing child-centered principles • Disadvantages of child-centered play therapy • • Did not offer immediate or short-term relief from symptoms Avoidance resulted in family upheaval Caregivers feel disconnected from process No skill-building, coping strategies, or problem-solving skills offered to child or parent • Posttraumatic repetitive play and avoidance of feared stimulus might continue into perpetuity
COGNITIVE-BEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN: NARROWING THE DIVIDE BETWEEN I DEOLOGY AND EVIDENCE Three possible treatments (cont. ) o Treatment option 3: Cognitive-behavioral play therapy • Basic tenets • Play used as vehicle to deliver CBT elements in developmentally sensitive ways • Both directive and child-led play therapy to accomplish play-based cognitive processing and restructuring • Play-based methods of assessment • Placing symptoms in boxes • Rating subjective units of distress on large thermometer • Play-based coping skills taught • Cardboard remote control • Coping fish game
COGNITIVE-BEHAVIORAL PLAY THERAPY FOR TRAUMATIZED CHILDREN: NARROWING THE DIVIDE B ETWEEN IDEOLOGY AND EVIDENCE Three possible treatments (cont. ) o Treatment option 3: Cognitive-behavioral play therapy (cont. ) • Play used to teach cognitive triangle • Dominoes labeled with unhelpful thoughts • Last domino labeled with a feeling • Trauma-related play narrative • • • Toy car, family figures, other props List of car safety rules with drawings First-aid kit for car Mother-child safety puppet show Teaching coping skills to puppets Creation of superhero boots, shield, car decorations, and rescue play scenario • Developmental concerns are important when considering CBT with children
THE WORRY WARS: A PROTOCOL FOR TREATING CHILDHOOD ANXIETY DISORDERS Introduction o Response to rising number of children who enter treatment with overwhelming anxiety o Worry Wars helps families “understand the core mechanisms that these disorders share and equips them to fight back against any manifestation of anxiety” (p. 129). Therapeutic interventions used in the Worry Wars protocol o Psychoeducation • Working definition of anxiety • Mechanism by which anxiety grows – avoidance • Examples how avoidance reinforces anxiety • Worry Wars is a developmentally sensitive way of delivering psychoeducation to children through • Play • Expressive arts • Metaphoric storytelling
THE WORRY WARS: A PROTOCOL FOR TREATING CHILDHOOD ANXIETY DISORDERS Therapeutic interventions used in the Worry Wars protocol (cont. ) • Cognitive restructuring • • Cognitive triad taught Identify anxiety-ridden thoughts Practice thought-stopping Craft and rehearse replacement statements • Systematic desensitization • Equip patient with relaxation strategies • Pairing fear-producing stimuli with relaxation • Gradual exposure • Hierarchy of exposures is arranged from easiest (least anxietyproducing) at bottom to most difficult at top • Exposures repeatedly paired with relaxation response
THE WORRY WARS: A PROTOCOL FOR TREATING CHILDHOOD ANXIETY DISORDERS Therapeutic interventions used in the Worry Wars protocol (cont. ) • Therapeutic storytelling • Metaphors “allow for the abstract concept to be given shape” (p. 132) • Anxiety can be depicted as the enemy • Facilitates recognition of anxious thoughts • Play therapy • In play, minds and bodies are engaged in an activity antithetical to anxiety reaction • Using toys allows children to communicate about their anxiety
THE WORRY WARS: A PROTOCOL FOR TREATING CHILDHOOD ANXIETY DISORDERS Mechanics of the Worry Wars protocol o The stories – give metaphoric form to childhood anxieties • “Daniel the Dragon Slayer” • Anxiety = dragon • Avoidance feeds dragon • Daniel uses “boss talk” and physically attacks dragon • “Polly Versus Princess Perfect” • Perfectionism or OCD = Princess Perfect • Self-talk combats Princess Perfect • Boss talk used • “Oscar Versus Clyde, the Clinging Octopus” • Separation anxiety = Clyde • Psychoeducation for Clyde that it is okay to separate from parents, ending as friends
THE WORRY WARS: A PROTOCOL FOR TREATING CHILDHOOD ANXIETY DISORDERS Mechanics of the Worry Wars protocol (cont. ) o The weapons – fight anxiety physiologically and cognitively • Each worry is represented as a paper worm and written down • Play therapy reduces avoidance behaviors as paper worms are placed in a container and sealed o Coping – identify differences between adaptive and maladaptive coping strategies and enhance positive coping • Copecakes – six positive coping strategies filling in the holes of the baking tin from four domains • • Should be good for you Should be good for others Should be easy to do Should make you feel better • Using support systems • Paper dolls with names of supportive people (for younger children) • Bookmarks with names of supportive people (for older children) • Parents taught SOOTHE strategies
THE WORRY WARS: A PROTOCOL FOR TREATING CHILDHOOD A NXIETY DISORDERS Mechanics of the Worry Wars protocol (cont. ) o Relaxation strategies • Deep, diaphragmatic breathing • • • Bubbles Personalized pinwheels Drawing soothing pictures Five Count Breathing Picture Perfect Postcards Chillin’ with my i. Pod – songs selected to make child feel calm or happy o The battles – structure exposure hierarchy • Least scary scenario at bottom of pyramid • Scariest scenario at top of pyramid • Tracking successful structures • Pulling off pieces of play-doh octopus • Placing paper bricks over dragon or princess o Graduation ceremony • Reflect on work done • Give honor to one another • Prepare for future encounters with anxiety
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